Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision.

The Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.

The Falcon Test: An Observer Agreement Study in Subjects With and Without Anterior Knee Pain.

Introduction: A shortened rectus femoris muscle has been associated with many different musculoskeletal problems. Assessing rectus femoris muscle length is commonly performed using the Modified Thomas Test. However, this test position is often difficult to assume and there are difficulties with reliably measuring rectus femoris length. A method that that uses an easier position to assume and could be more reliable would be beneficial to therapists. The purpose of this study was to determine observer agreement using a new test for assessment of rectus femoris length. A second purpose was to determine if those with anterior knee pain have different rectus femoris muscle length than those without anterior knee pain. Method: Fifty-three participants with and without anterior knee pain were enrolled. Rectus femoris muscle length was measured lying prone with the leg measured on the table while the non-measured leg was off the table in a position of 90° hip flexion. Rectus femoris muscle was lengthened by passively bending the knee until a firm end-feel. The angle of knee flexion was then measured. The process was then repeated after a brief rest period. Results: Observer agreement assessing rectus femoris length using this method showed "almost perfect" reliability for both intra- and inter-rater testing: intra-rater: ICC = .99, [CI95: .98-.99], inter-rater: ICC = .96, [CI95: .92- .98]. Agreement for the sub-sample of those with anterior knee pain (N=16) showed "almost perfect" reliability for intra-rater (ICC 1,1 = .98); [CI95: 0.94-.99] and inter-rater reliability (ICC 2,1 = 0.88); [CI95: 0.70 -.95]. No differences were noted in rectus femoris length between those without and those with anterior knee pain (t= 0.82, p> 0.01); [CI95: -7.8 -3.33]; (SEM = 1.3°; MDC=3.6°). Conclusion: This new method of assessing rectus femoris length is reliable between and within raters. No differences were noted in rectus femoris length between those with anterior knee pain and those without.

Hamstring Strain Injury in Athletes.

Hamstring strain injury (HSI) may result in considerable impairment, activity limitation, and participation restriction, including time lost from competitive sports. This CPG includes sports-related overloading and overstretching injuries to myofascial or musculotendinous structures in any combination of the 3 hamstring muscles (the semitendinosus, semimembranosus, and biceps femoris). J Orthop Sports Phys Ther 2022;52(3):CPG1-CPG44. doi:10.2519/jospt.2022.0301.

The Conundrum of Kappa and Why Some Musculoskeletal Tests Appear Unreliable Despite High Agreement: A Comparison of Cohen Kappa and Gwet AC to Assess Observer Agreement When Using Nominal and Ordinal Data.

In clinical practice, physical therapists often use different kinds of tests and measures in the assessment of their patients. For therapists to have confidence when using their tests and measures, an important attribute is having intratester and intertester reliability. Studies that assess reliability are cases of observer agreement. Many studies have been performed assessing observer agreement in the physical therapy literature. The most commonly used method to assess observer agreement studies that use nominal or ordinal data is the statistical method suggested by Cohen and the corresponding reliability coefficient, Cohen kappa. Recently, Cohen kappa has undergone scrutiny because of what is called kappa paradox, which occurs when observer agreement is high but the resulting kappa value is low. Another paradox also occurs when asymmetries exist between raters on their disagreements, resulting in a higher kappa value. In the physical therapy literature, there are numerous examples of this problem, which can often lead to misunderstanding the meaning of the data. This Perspective examines how and why these problems occur and suggests an alternative method for assessing observer agreement.

How weakness of the tensor fascia lata and gluteus maximus may contribute to ACL injury: A new theory.

Anterior cruciate ligament (ACL) injuries are common in sports including a significant failure rate following reconstruction. The iliotibial band (ITB) is an important stabilizer of the lateral portion of the knee and also an important lateral rotator of the tibia. Both the tensor fascia lata (TFL) and gluteus maximus (Gmax) muscles insert into the ITB proximally. This paper describes a theory that implicates weakened TFL and Gmax muscles as possible contributors to anterolateral rotatory instability. If the TFL and Gmax are important contributors to anterolateral rotatory instability, physical therapists can emphasize assessing for their weakness and developing a rehabilitation program to restore their strength.

CHANGES IN PELVIC TILT DURING THREE DIFFERENT RECIPROCAL STANCE POSITIONS IN PATIENTS WITH SACROILIAC JOINT REGIONAL PAIN.

PURPOSE: Essential to the successful management of patients with sacroiliac joint pain (SIJP) is understanding how these joints move. The innominates tilt together in the same direction with symmetrical activities (i.e. forward-bending) but move opposite of one another when performing asymmetrical activities (i.e. walking). How they move in patients with SIJP is unknown. The purpose of this study was to examine inter-innominate movement (tilt) when assuming three different stance positions to describe how the innominate bones move in those with and without SIJP. STUDY TYPE: Observational Cohort Study. METHODS: Twenty-eight participants were classified into two groups; SIJP with low back pain (LBP), and no SIJP or LBP. SIJP participants were further classified into groups with left or right pelvic tilt. Pelvic tilt was measured during neutral standing and in both left-sided and right-sided reciprocal stance, with a full-stride (one hip fully flexed the other fully extended) and in a half-stride position, which mimic the double-stance phase of gait. A repeated measure ANOVA assessed for differences between Groups (Level, Left or Right Pelvic Tilt), stance side position (left/right), and stride length (full/half). RESULTS: The was a significant Group main effect (F [2, 25] = 130.2, p < 0.0001), and a significant Side main effect (F [1, 25] = 429.7, p < 0.0001), qualified by a significant Side x Group interaction (F [2, 25] = 19.9 p < .0001). Follow-up comparisons showed that pelvic tilts for right and left stance were significantly different (p < 0.05) for each group (Level, left and right pelvic tilt). For the right stance condition, all groups were significantly different from each other (p < 0.05). For the left stance position, the right pelvic tilt and level pelvic tilt means were not different from each other (p > 0.05), but each was different from the mean for the left pelvic tilt group (p < 0.05). CONCLUSIONS: When assuming an asymmetrical stance position, the innominates tilt opposite of each other in those without SIJP. In patients with SIJP they behave in the normal fashion in one asymmetrical stance position but not the other. Instead of tilting opposite, as expected, the innominates remain symmetrical, dependent on the side of the presenting pelvic tilt. LEVEL OF EVIDENCE: 2b.

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

April 2017 Letter to the Editor-in-Chief.

Letter to the Editor-in-Chief of JOSPT as follows: "Subgrouping Patients With Low Back Pain" with Authors' Response J Orthop Sports Phys Ther 2017;47(4):295. doi:10.2519/jospt.2017.0203.

The reliability of assessing sternocleidomastoid muscle length and strength in adults with and without mild neck pain.

BACKGROUND: The sternocleidomastoid (SCM) is an important cervical spine muscle. Weakness of the SCM muscle has been implicated with cervical problems. No studies have examined the reliability of assessing the SCM muscle length or strength. Also no studies exist that have looked to see if imbalances in SCM muscle length or strength exists between the left and right sides in those with and without neck pain. OBJECTIVE: To determine the reliability of assessing the SCM muscle for length and strength and to see if SCM length could predict SCM strength in those with and without neck pain. DESIGN: Cross-sectional study. METHODS: Fifty-one subjects with and without mild neck pain. ANALYSIS: Intratester reliability was assessed for SCM muscle length and SCM muscle strength. Differences in SCM length and strength were examined in those with and without neck pain. RESULTS: Intratester reliability was shown to be excellent (ICC (2,2) > 0.90) for the left and right SCM when assessing muscle length and muscle strength for those with and without neck pain. No differences were noted when comparing left to right SCM between those with and without neck pain regarding muscle length or muscle strength. Neither regression models were able to predict SCM muscle strength from SCM muscle length. CONCLUSION: SCM muscle length and SCM strength can be reliably assessed using a bubble goniometer and HHD. No differences were found when comparing left to right SCM muscle length or strength in those with or without mild neck pain.

PREDICTING FOOT PROGRESSION ANGLE DURING GAIT USING TWO CLINICAL MEASURES IN HEALTHY ADULTS, A PRELIMINARY STUDY.

BACKGROUND: The foot progression angle (FPA) is related to the transverse plane rotation of the lower extremities and associated with many lower extremity conditions. PURPOSE: The purpose of this study was to examine how two commonly used clinical measures, tibio-fibular torsion (TF) and hip rotation, can be used to predict FPA during gait in healthy adults. STUDY DESIGN: Cross-sectional study design. METHODS: Passive hip internal and external rotation ranges of motion and TF torsion were measured with a 12-inch goniometer while the FPA (degree of toe-in/out) was measured with the GAITRite during midstance in sixty participants. The data was analyzed using a multiple regression model. RESULTS: Hip ER was not significant and was therefore excluded from the final model. The final model included passive hip IR and TF torsion (F = 19.64; p < .001; multiple R(2) = .41; adjusted R(2) = .39). Simple binary correlations showed that hip IR had a moderate negative correlation (r = -.40) with FPA (the greater the hip IR, the greater the in-toeing) while TF torsion had a positive correlation (r = .39) with FPA (the greater the external TF torsion. the greater the out-toeing). CONCLUSIONS: Greater amount of passive hip IR predicts in-toeing while greater TF torsion predicts out-toeing of the foot during midstance phase of gait. LEVEL OF EVIDENCE: Level 2.

THE RELATIONSHIP BETWEEN PASSIVE GLENOHUMERAL TOTAL ROTATION AND THE STRENGTH OF THE INTERNAL AND EXTERNAL ROTATOR MUSCLES, A PRELIMINARY STUDY.

BACKGROUND: There is little research on how the amount of shoulder joint range of motion, specifically glenohumeral rotation, may be related to the muscle strength of the rotator cuff muscles. A long held belief is that a joint with excessive range of motion needs sufficient muscular strength for stability. However, no studies have examined this concept. PURPOSE: The purpose of this study was to see if total arc of glenohumeral joint rotation (External rotation [ER]+Internal rotation [IR]) could predict peak isometric muscle strength of the IR or ER muscles of the shoulder. STUDY DESIGN: Cross-sectional study design. METHODS: Fifty-three participants (41 females, 12 males) participated in the study. Passive glenohumeral joint internal rotation and external rotation motion was measured for each participant with a standard goniometer. Isometric muscle force of the ER and IR muscles were tested using a handheld dynamometer in three positions: end range ER, neutral 0°, and end range IR. Data were analyzed using a non-parametric tree based regression method (CART) and then cross-validated. RESULTS: The results showed that those with an increased total arc of motion of glenohumeral rotation (greater than 165.0°) had less muscle isometric muscle strength in all tests positions than those with less glenohumeral rotation. CONCLUSION: Decreased force of the ER and IR muscles of the shoulder was noted in those with increased total arc glenohumeral rotation ( > 165.0°), specifically those with increased glenohumeral internal rotation ( > 80.0°) when compared to those with glenohumeral rotation ( < 165.0°) and glenohumeral internal rotation ( < 80.0°). Future studies should include more males and attempt to develop strategies to assist those with larger excursions of shoulder rotation who may be at risk of developing shoulder problems. LEVEL OF EVIDENCE: Level 2.

Nonarthritic hip joint pain.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to nonarthritic hip joint pain.

The influence of muscle length on one-joint shoulder internal and external rotator muscle strength.

BACKGROUND AND PURPOSE: Kendall suggests testing the rotator cuff muscles in their maximally shortened position, since one-joint muscles are thought to be strongest. We found little evidence to support this concept. The purpose of this study was to determine if the shoulder internal rotator (IR) and external rotator (ER) muscles are strongest when placed in their shortened length position. METHODS: Fifty-three subjects participated. Glenohumeral joint internal rotation and external rotation motion was measured. Muscle strength was then tested using a hand-held dynamometer in four positions: (1) end-range ER; (2) neutral 0°; (3) glenohumeral joint mid-range and (4) end-range IR. Data were analyzed using two repeated measures ANOVA's. RESULTS: The results suggest that rotator muscle strength is dependent on muscle length. IR strength was weakest at end-range IR in its shortest length; ER muscle strength was weakest at end-range ER in its shortest length. Muscle strength of the IR or ER was not significantly different when comparing neutral 0° to the mid-range position and at their most lengthened position. CONCLUSION: The IR and ER muscles were found to be weakest when placed in a position of shortest muscle length, while the neutral 0° and mid-range positions were the strongest positions.

Sacroiliac joint dysfunction as a reason for the development of acetabular retroversion: a new theory.

Acetabular retroversion has been recently implicated as an important factor in the development of femoral acetabular impingement and hip osteoarthritis. The proper function of the hip joint requires that the anatomic features of the acetabulum and femoral head complement one another. In acetabular retroversion, the alignment of the acetabulum is altered where it opens in a posterolaterally instead of anterior direction. Changes in acetabular orientation can occur with alterations in pelvic tilt (anterior/posterior), and pelvic rotation (left/right). An overlooked problem that alters pelvic tilt and rotation, often seen by physical therapists, is sacroiliac joint dysfunction. A unique feature that develops in patients with sacroiliac joint dysfunction (SIJD) is asymmetry between the left and right innominate bones that can alter pelvic tilt and rotation. This article puts forth a theory suggesting that acetabular retroversion may be produced by sacroiliac joint dysfunction.

A new manual muscle test for assessing the entire trapezius muscle.

UNLABELLED: Manual muscle testing (MMT), the trapezius muscle is an important part of the examination in patients with upper extremity dysfunction or pain. PURPOSE: The purpose of this study was to assess the reliability and validity of a new MMT that assesses the entire trapezius muscle instead of the usual method of separating it into three different parts. The new trapezius MMT is similar to the serratus anterior muscle test; however, the testing is performed in the frontal versus sagittal plane. METHODS: A convenience sample of 11 subjects was recruited with no known shoulder pathology. Surface electromyography electrodes were placed on the upper, middle, and lower trapezius fibers according to a previously validated method and MMTs for the three different trapezius muscle test positions were normalized against the new trapezius test position. RESULTS: The new trapezius MMT showed very high maximal voluntary isometric contraction (MVIC; 160.80%) for the upper trapezius muscle, high for the middle trapezius muscle (59.23%), and high for the lower trapezius muscle (47.54%) when normalized against the MVICs for each individual trapezius muscle tests. CONCLUSIONS: A new MMT that assesses the whole trapezius in its role as an upward scapular rotator was found to be reliable and valid.